Integrated Cancer Care – A patient-centric approach to breast cancer treatment

Medical Director, Orchids Breast Health, Pune, India 

Research Lead, Centre for Translational Cancer Research (CTCR), Pune India 

Member, Board of Directors, Indian Cancer Genome Atlas (ICGA), India 

Founding Director International School of Oncoplastic Surgery (ISOS), India 

Honorary Associate Professor, University of East Anglia, UK 

Board of Directors and Visiting Faculty, School of Oncoplastic Surgery, CA, USA 

Founding Director, Breast Global Network, India and UK 

Managing Trustee, Prashanti Cancer Care Mission, Pune, India 

www.drkoppiker.in 

Pune (Maharashtra) [India]: Breast cancer management is witnessing a paradigm shift from a disease focussed approach to a more patient-centric approach. Oncological treatment is often associated with physical and psychological side effects that extend into the recovery phase as well. In middle-income countries like India, these are further aggravated by low socioeconomic status, lack of awareness of disease symptoms and the possible financial burden of the treatment. Additionally, women in India face several societal pressures wherein the household is emotionally and physically dependent on them. As a result, they are often reluctant to seek medical help and feel a sense of guilt or shame after diagnosis (1,2). These elements are a major contributing factor to the late detection of breast cancers in India (3).

In a country grappling with lack of awareness and need for early detection of breast cancer, the impact of the disease on quality of life often takes a backseat. Integrative oncology involves the inclusion of complementary therapies to mainstream cancer management so as to mitigate the side effects of oncological treatment and enhance physical and emotional well-being during and post-treatment. In high-income countries, integrative therapies are now being included in mainstream cancer management so as to improve overall quality of life for the patient (4). However, in India, inclusion of complementary therapies such as nutrition, genetic and onco-psychology counselling is still in very nascent stages.

In my practice, we have a multi-disciplinary approach towards breast cancer management. Being a single surgeon practice with expertise in oncoplasty the surgical approach towards breast cancer treatment at our centre is different than the rest of India. I believe that no woman should lose her breast to cancer and hence have always strived to establish Breast Oncoplasty in India. Oncoplastic techniques enable the aesthetic conservation of the breast while achieving superior oncological outcomes. Although mastectomy or removal of the breast is associated with severe sequale and poor quality of life, it is still the most common approach to breast cancer management in India (5). Breast Conserving Surgery aided with oncoplastic in some difficult situations offers better cosmesis and is reported to show better patient satisfaction and quality of life. In addition to providing oncoplastic options for surgical management of breast cancer, we also have a supportive care unit that focuses on quality of life during and post-treatment. This supportive care unit includes a team of doctors, counselors, and nurses who care for the patient’s quality of life, decreasing side effects and focusing on a better prognosis. Patient-centric programs including Genetic counseling and testing, Oncopsychology counseling, Yoga, and nutrition counselling and Annual Patient Reported Outcome Measures (PROMs) are undertaken to enhance the Quality of Life (QoL) for both breast cancer patients and survivors.

One-to-one oncopsychology counselling is provided to patients to help them cope with any psychological or emotional distress. For patients who may have hereditary breast cancer, genetic counselling and subsidized genetic testing is offered. The genetic counsellor discusses the importance of genetic testing as well as how the results would affect the patient and/or her family members. Diet and physical activity are also known to be essential during cancer treatment, to improve side effect management, enhance compliance to protocols and avoid malnutrition (4,6,8). The nutrition counselling involves a detailed understanding of the patients’ existing dietary habits based on which personalized diet charts, simple recipes, and home remedies for side effects are provided and followed up. We also encourage regular physical activity by offering yoga counselling. These are led by certified yoga and naturopathic practitioners and can be found on our YouTube channel. During the pandemic, we created an online workflow to continue providing yoga treatment and nutrition advice to our patients

Taking into consideration that patients should have a carefree and disease-free life post-breast cancer, my practise has a robust follow-up protocol. We take additional measures to follow up with our patients and report the patient’s concerns about health through a systematic questionnaire targeted to improve health literacy (HL) by addressing social, psychological, and sexual wellbeing and any other issues that may be faced by a breast cancer survivor. Such systematic questionnaires, referred to as PROMs (patient-reported outcome measures) are effective tools to capture data on the overall health of breast cancer survivors (9). PROMs are administered post-surgery consecutively for 5 years and depending on these answers qualitative data is collected and interpretations are made on the individual’s QoL.

Health literacy (HL) implies the ability to access, understand, appraise and apply health information (10). It is essential to improve health literacy in India, as a major portion of the population lacks awareness about breast cancer and its available treatment options. Through various media like print, interviews, and patient-centric webinars we try to make the community aware of the various treatment options available for Breast Cancer, facilitating HL in the population. Additionally, patient-centric projects to understand patient involvement and understanding of nutrition, exercise and genetics in breast cancer management are ongoing at the center. It is our belief that attention to health literacy at the individual level is necessary in order to provide exemplary survivorship care.

To enhance its efforts regarding HL in the community and in its patient population, my practice has also newly initiated eHealth Literacy surveys. These will help in not only assessing the impact of our awareness initiatives but also help in changing the perspective about breast cancer. Overall, there is low health and cancer literacy among Indian women as compared to the western population (11). It is essential that along with incorporation of an integrative approach to cancer management, the health literacy in the population is also given a boost.

Our experiences emphasize the need for a comprehensive multi-disciplinary approach to breast cancer management. It is essential that more centres in India replicate our model and incorporate a comprehensive breast cancer management protocol to ensure improved quality of life and overall well-being for breast cancer patients and survivors.

References: 

1. Daniel, S., Venkateswaran, C., Hutchinson, A. & Johnson, M. J. ‘I don’t talk about my distress to others; I feel that I have to suffer my problems…’ Voices of Indian women with breast cancer: a qualitative interview study. Support Care Cancer 29, 2591–2600 (2021). 

2. Rajpal, S., Kumar, A. & Joe, W. Economic burden of cancer in India: Evidence from cross-sectional nationally representative household survey, 2014. PLoS ONE 13, e0193320 (2018). 

3. Kumar, A. et al. Delays in Diagnosis and Treatment of Breast Cancer and the Pathways of Care: A Mixed Methods Study from a Tertiary Cancer Centre in North East India. Asian Pac J Cancer Prev 20, 3711–3721 (2019). 

4. Magno, S., Filippone, A. & Scaldaferri, A. Evidence-based usefulness of integrative therapies in breast cancer. Transl. Cancer Res 7, S379–S389 (2018). 

5. Thakur, M., Sharma, R., Mishra, A. K., Singh, K. & Kar, S. K. Psychological distress and body image disturbances after modified radical mastectomy among breast cancer survivors: A cross-sectional study from a tertiary care centre in North India. The Lancet Regional Health – Southeast Asia 7, 100077 (2022). 

6. Link, A. R. et al. Use of Self-Care and Practitioner-Based Forms of Complementary and Alternative Medicine before and after a Diagnosis of Breast Cancer. Evidence-Based Complementary and Alternative Medicine 2013, 1–16 (2013). 

7. Danhauer, S. C. et al. Restorative yoga for women with ovarian or breast cancer: findings from a pilot study. J Soc Integr Oncol 6, 47–58 (2008). 

8. Lo-Fo-Wong, D. N. N., Ranchor, A. V., de Haes, H. C. J. M., Sprangers, M. A. G. & Henselmans, I. Complementary and alternative medicine use of women with breast cancer: self-help CAM attracts other women than guided CAM therapies. Patient Educ Couns 89, 529–536 (2012). 

9. Pusic, A. L. et al. Development of a new patient-reported outcome measure for breast surgery: the BREAST-Q. Plast Reconstr Surg 124, 345–353 (2009). 

10. Sørensen, K. et al. Health literacy and public health: A systematic review and integration of definitions and models. BMC Public Health 12, 80 (2012). 

11. Gupta, A., Shridhar, K. & Dhillon, P. K. A review of breast cancer awareness among women in India: Cancer literate or awareness deficit? European Journal of Cancer 51, 2058–2066 (2015).

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